Table Of ContentMAGNETIC RESONANCE IMAGING OF BONE AND SOFT
TISSUE TUMORS AND THEIR MIMICS
SERIES IN RADIOLOGY
Volume 20
1. J. Odo Op den Orth, The Standard Biphasic-Contrast Examination of the Stomach and Duodenum:
Method, Results and Radiological Atlas.
1979. ISBN 9024721598
2. J.L. Sellink and R.E. Miller, Radiology of the Small Bowel. Modem Enteroclysis Technique and
Atlas.
1981. ISBN 902472460 0
3. R.E. Miller and J. Skucas, The Radiological Examination of the Colon. Practical Diagnosis.
1983. ISBN 902472666 2
4. S. Forgacs, Bones and Joints in Diabetes Melitus.
1982. ISBN 90 247 2395 7
5. G. Nemeth and H. Kuttig, Isodose Atlas. For Use in Radiotherapy.
1981. ISBN 9024724767
6. J. Chermet, Atlas of Phlebography of the Lower Limbs, including the Iliac Veins.
1982. ISBN 9024725259
7. B. Janevski, Angiography of the Upper Extremity.
1982. ISBN 9024726840
8. M.A.M. Feldberg, Computed Tomography of the Retroperitoneum. An Anatomical and Pathological
Atlas with Emphasis on the Fascial Planes.
1983. ISBN 0898385733
9. L.E.H. Lampmann, S.A. Duursma and J.HJ. Ruys, CT Densitometry in Osteoporosis. The Impact on
Management of the Patient.
1984. ISBN 0898386330
10. J,J. Broerse and TJ. MacVittie, Response of Different Species to Total Body Irradiation.
1984. ISBN 0 89838 678 0
11. C. L'Hermine, Radiology of Liver Circulation.
1985. ISBN 0898387159
12. G. Maatman, High-resolution Computed Tomography of the Paranasal Sinuses, Pharynx and Related
Regions.
1986. ISBN 0 89838 802 3
13. C. Plets, AL. Baert, G.L. Nijs and G. Wilms, Computer Tomographic Imaging and Anatomic
Correlation of the Human Brain.
1986. ISBN 089838811 2
14. J. Valk, MRI of the Brain, Head, Neck and Spine. A Teaching Atlas of Clinical Applications.
1987. ISBN 0898389577
15. J.L. Sellink, X-Ray Differential Diagnosis in Small Bowel Disease. A Practical Approach.
1988. ISBN 089838351 X
16. T.H.M. Falke, ed., Essentials of Clinical MRI.
1988. ISBN 0898383536
17. B.D. Fomage, ed., Endosonography.
1989. ISBN 0792300475
18. R. Chisin and AL Weber, eds., MRI/CT and Pathology in Head and Neck Tumors. A Correlative
Study.
1989. ISBN 0792302273
19. G. Gozzetti, A. Mazziotti, L. Bolondi, L. Barbara, eds., Intraoperative Ultrasonography in Hepato
Biliary and Pancreatic Surgery. A Practical Guide.
1989. ISBN 0792302613
MAGNETIC RESONANCE IMAGING
OF BONE AND SOFT
TISSUE TUMORS AND
THEIR MIMICS
A C finical Atlas
A.M.A. DE SCHEPPER
and
H.R.M. DEGRYSE
Department of Radiology,
University Hospital Antwerp, Belgium
with contributions by
F. De Belder
L. van den Hauwe
F. Ramon
P. Parizel
N. Buyssens
KLUWER ACADEMIC PUBLISHERS
DORDRECHT I HOSTON I LONDON
ISBN-13: 978-94-010-6938-0 e-ISBN-13: 978-94-009-0997-7
DOl: 10 .1007/ 978-94-009-0997-7
Published by Kluwer Academic Publishers,
P.O. Box 17, 3300 AA Dordrecht, The Netherlands.
Kluwer Academic Publishers incorporates
the publishing programmes of
D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press.
Sold and distributed in the U.S.A. and Canada
by Kluwer Academic Publishers,
101 Philip Drive, Norwell, MA 02061, U.S.A.
In all other countries, sold and distributed
by Kluwer Academic Publishers Group,
P.O. Box 322,3300 AH Dordrecht, The Netherlands.
All Rights Reserved
© 1989 by Kluwer Academic Publishers
Softcover reprint of the harcover 1st edition 1989
No part of the material protected by this copyright notice may be reproduced or
utilized in any form or by any means, electronic or mechanical
including photocopying, recording or by any information storage and
retrieval system, without written permission from the copyright owner.
PREFACE
Magnetic resonance imaging has already become a most valuable
imaging modality in the diagnostic work-up of musculoskeletal
neoplasms. While high accuracy of MRI for staging purposes has been
proven, we will focus in this monograph on the characterization of
primary bone and soft tissue tumors by MRI.
The major purpose of this monograph is to provide an atlas of magnetic
resonance features of primary bone and soft tissue tumors for
radiologists, orthopedic surgeons and physiotherapists.
The results presented are based on investigations of 94 primary bone
and soft tissue tumors and mimicking conditions by magnetic
resonance imaging. Although the scale of the material allows for
statistical handling, the number of patients per subgroup is too small to
come to definite conclusions.
We will therefore limit ourselves to the description of and comments on
a great number of cases to illustrate the diagnostic potential of this new
imaging modality.
We would like to thank the anonymous cooperators: referring clinicians,
pathologists, nurses, technicians and secretaries whose help enabled
us to present this monograph. We would also like to express our
gratitude to the firms Siemens AG and Schering AG for technical
support.
This monograph results from the will to do clinical-scientific research
with and despite the limited manpower and infrastructure of a small but
dynamic university department.
2
Key to abbreviations
CR Conventional radiography
CT Computed tomography
DSA Digital subtraction angiography
MR Magnetic resonance
MRI Magnetic resonance imaging
RNSC Radionuclide scintigraphy
SE Spin echo
SI Signal intensity
WI Weighted images
3
CONTENTS
1 General Considerations about Bone and Soft Tissue Tumors 5
2 Materials and Methods 21
Benign Bone Tumors and Mimicking Conditions
3 Osteoid Osteoma 25
4 Enchondroma 31
5 Osteochondroma 34
6 Giant Cell Tumor 39
7 Vertebral Hemangioma 44
8 Solitary Bone Cyst 50
9 Aneurysmal Bone Cyst 52
10 Non Ossifying Fibroma 56
11 Eosinophilic Granuloma 58
12 Fibrous Dysplasia 61
13 Osteomyelitis 69
Malignant Bone Tumors
14 Osteogenic Sarcoma 75
15 Chondrosarcoma 75
Benign Soft Tissue Tumors
16 Lipoma 98
Neurogenic Tumor 99
Soft Tissue Hemangioma 102
Aggressive Fibromatosis 104
Malignant Soft Tissue Tumors
17 Liposarcoma 109
18 Malignant Fibrous Histiocytoma 115
19 Rhabdomyosarcoma 118
20 Value of Contrast (Gd-DTPA)-Enhanced MRI Studies in Cases
of Musculoskeletal Tumors 123
21 General Conclusions 129
5
CHAPTER 1 :
GENERAL CONSIDERATIONS ABOUT BONE AND
SOFT TISSUE TUMORS:
1.1 INTRODUCTION:
Medical imaging and histopathology are both essential in the study of
musculoskeletal neoplasms. The complementarity of both methods has
been stressed to the best by R.Freiberger in his article" Thoughts on the
Diagnosis of Bone Tumors" (7). Its abstract will serve as an introduction
and a guide throughout the material discussed below:
'The pathologist and the radiologist have each been given reason to believe
that he is capable of accurately diagnosing bone tumors without the
assistance of the other. However, each specialist has recourse to tools
and procedures not available to the other, and their findings should be
considered as complementary. Although there are radiographic features
which could be an indication of malignancy, there are too many common
exceptions to formulate a general rule. Likewise, although the pathologist
can examine microscopic morphology and obtain biochemical information
using special stains, the sample being examined may not be representative
of the entire tumor. Thus the ultimate benefit to the patient can be obtained
only if the radiologist and pathologist work in concert with one another
and with the surgeon toward the common goals of accurate diagnosis and
prompt, appropriate management of bone tumors. '
Two cases of our series dramatically illustrate the need for a permanent
confrontation of radiological and pathological data.
In the case of L.V., a 14 year-old female, clinical data as well as findings
on various imaging techniques indicate the presence of an osteoid osteoma
(Fig. 1.1).
Histological examination only shows 'highly compact bone layers with
irregular and dilated Haversian canals: signs indicating a hyperostotic
lesion.' Although clearly demonstrated by all imaging methods, the
characteristic" nidus" was not visualized histologically.
The results of the radio-pathological confrontation, however, allow an
almost certain diagnosis of osteoid osteoma.
A second illustrative case concerns D.P.D., a 9 year-old boy, presenting
with pain in the region of the left fibula, after a sport injury (Fig. 1.2). On
CR a bony lesion at the fibular diaphysis is found. Despite its geographical
appearance, suggesting a benign condition, no sclerotic margins are
recognized and there is a slight disruption in the periosteal new bone
formation at the medial border of the lesion (Fig. 1.2.a). On CT there is
evidence of a subtle, unsharply delineated, hypodense paracortical area
(Fig. 1.2.d).
On MRI, the central intramedullary lesion has a relatively high SI [4] on
T1-WI (Fig 1.2.b), whereas the semilunar paracortical area has an increased
SI [6] on T2-WI (Fig. 1.2.c).These findings are not consistent with a benign
lesion. Because of the discrepancy between the clinical and radiological
findings, the lesion has been removed surgically. Histological examination
shows' a pronounced periosteal reaction and irregular Haversian canals.
The lesion itself is cystic and contains a highly proteinaceous fluid. The
cyst is complicated by a concomitant pathologic fracture.
Retrospectively, these findings explain the MRI-characteristics of the lesion:
the high protein concentration in the fluid shortens the T 1-relaxation time
and causes an increased SI. The periosteal reaction is a consequence of
the pathologic fracture. The paracortical lesion on CT as well as on MRI
corresponds to a non-recent hemorrhage, as reflected by the prolongation
of the T2-relaxation time.
6
Fig. 1.1. L.V., 14 year-old female.
1. l.a. CR of the middle third of the left
tibia. Localized cortical thickening and
hyperostosis at the lateral border of
the tibia (arrows). A small central
lucent area within the hyperostotic
region is noted (curved open arrow).
1. l.b. CT at the level of the lesion, bone
window.
Cortical thickening by hyperostosis
is confirmed. The enclosed lucent
area is clearly demonstrated.
1.I.c. MRI of the lower legs, coronal
section, Tl-WI.
The area of hyperostosis is seen as
a fusiform broadening of cortical signal
void. Geographical area of decreased
SI in the adjacent bone marrow.
1.1.d. MRI at the level of the lesion,
transverse section, T2-WI.
Again, cortical hyperostosis presents
as an enlargement of the cortical
signal void. Within it a small
hyperintense fleck is observed (arrow).
1. Ie.. Microphotograph of biopsy specimen
(Courtesy Prof Van Damme, KUL).
Dense osseous tissue with small
marrow cavities. Reactive hyperplasia.
Absence of nidus.
Diagnosis: Osteoid osteoma of the tibia.
Although not demonstrated
pathologically, a nidus was clearly
shown by various imaging techniques.
7
Fig. 1.2. D.P.D., 9 year-old male.
1.2.a. CR of the proximal part of the left
lower leg.
Slightly expansive lesion in the proximal
part of the fibular diaphysis, causing
endosteal scalloping. Absence of
sclerotic rim. Periosteal elevation,
pronounced at the lateral fibular margin.
Slight disruption at the medial border.
1.2.b. MRI of the left fibula, coronal
section, Tl-WI.
The intramedullary lesion presents
with decreased SI [3] compared to
normal bone marrow. Endosteal
scalloping and periosteal reaction are
also seen.
1.2.c. MRI of the left fibula at the level
of the lesion, transverse section,
T2-WI. Markedly raised SI of the
medullary component of the lesion
[7]. Moderate increased Sl [6] in the
adjacent muscle, posteriorly and
medially to the lesion (arrows).
1.2.d. CT of the left fibula at the level of
the lesion, soft tissue window.
Enlargement of the medullary cavity,
indicating expansive intramedullary
lesion, is seen. Slight ill defined
hypodense area in adjacent muscle
(arrows).
1.2.e. Microphotograph. (Courtesy Prof
Van Damme, KUL)
Margin of simple bone cyst:
1/ lumen,
2/ pre-existing cortical bone with
pressure atrophy,
3/ new bone formation,
4/ periosteal connective tissue,
5/ striated muscle.
Diagnosis: Juvenile bone cyst. complicated
by pathological fracture
